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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002454
Report Date: 09/10/2024
Date Signed: 09/10/2024 12:15:38 PM

Document Has Been Signed on 09/10/2024 12:15 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:JOAQUIN HOMEFACILITY NUMBER:
455002454
ADMINISTRATOR/
DIRECTOR:		CAMPBELL, JENNIFERFACILITY TYPE:
735
ADDRESS:662 JOAQUIN AVENUETELEPHONE:
(530) 722-9205
CITY:REDDINGSTATE: CAZIP CODE:
96002
CAPACITY: 4CENSUS: 3DATE:
09/10/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Robert HolmesTIME VISIT/
INSPECTION COMPLETED:
12:35 PM
NARRATIVE
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On 09/10/2024, Licensing Program Analyst (LPA) Ivan Avila arrived unannounced at the facility to conduct a case management visit regarding absent without leave incident reports (AWOL) the Department received via fax on 07/30/24, 08/18/24, and 09/2/24. LPA met with Administrator Robert Holmes and explained the purpose of the visit.

The first incident occurred on 07/29/24 when C1 AWOL'd the facility at approximately 1 AM without staff's knowledge and walked to a local middle school down the street from the facility. Approximately 30 minutes later the school security guard found C1. C1 asked the security guard to call an ambulance. He was picked up and sent over to the hospital for observation. C1 was discharged at the hospital at 6 AM when staff had picked C1 up and drove him back to the facility. The second incident occurred on 08/31/24 where C1 left the facility at three different time periods. C1 left the facility at 1:23 PM, again at 3:20 PM, and a third time at 6:11 PM when Redding Police Department arrested C1 for assault on a police officer. C1 was taken to Shasta County Jail for a few days and send home on 09/5/24.

The third incident occurred on 08/16/24 when C2 AWOL'd the facility at approximately 4:55 PM. Staff alerted local law enforcement that C2 had left the facility and did not know where he was. Staff and the on-call Administrator began to look for C2 and approximately 30 minutes later law enforcement called the Administrator stating C2 was down the street at the local golf course. C2 had gone to the golf course and walked into a body of water where local bystanders redirected C2 out of the water and called an ambulance. C2 was evaluated with no injuries and sent back to the facility.

----Continued on LIC809-C----

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Ivan Avila
LICENSING EVALUATOR SIGNATURE: DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: JOAQUIN HOME
FACILITY NUMBER: 455002454
VISIT DATE: 09/10/2024
NARRATIVE
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Although no injuries resulted from C1 and C2’s AWOL incidents on 07/29/24, 08/16/24, and 08/31/24, C1 and C2’s physician reports (LIC 602) indicate they were unable to leave the facility unassisted.

LPA and Administrator discussed the importance of the health and safety of clients in care. LPA and Administrator also discussed the importance of providing more staff at the facility to provide proper care and supervision to all clients.

As a result of the incidents, a deficiency is being cited per California Code of Regulations, Title 22, and California Health and Safety Code. The deficiency is documented on the LIC 809-D page.

Exit interview conducted, a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Ivan Avila
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/10/2024 12:15 PM - It Cannot Be Edited


Created By: Ivan Avila On 09/10/2024 at 11:52 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: JOAQUIN HOME
FACILITY NUMBER: 455002454

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/13/2024
Section Cited
CCR
85065(b)

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85065(b) The licensee shall employ staff as necessary to ensure provision of care and supervision to meet client needs.
This requirement is not met as evidence by:
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Facility will complete a statement of understanding regarding regulation 85065(b). Facility will submit statement of understanding to LPA by POC due date of 09/13/2024.
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Based on document review and interview, the Licensee did not comply in the section cited above as clients eloped the facility and did not ensure the care and supervision to meet client needs, which poses an immediate health, safety, and personal rights risk to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Anthony Perez
LICENSING EVALUATOR NAME:Ivan Avila
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2024


LIC809 (FAS) - (06/04)
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